Bloaters and Belchers

Excessive belching, as per Rome IV, is when it is bothersome enough to disrupt usual activities and occurs more than 3 days per week. It may occur either as an isolated symptom or may be associated with GERD, functional dyspepsia, gastroparesis, anxiety and pregnancy.

Functional bloating and distension is diagnosed when recurrent symptoms of abdominal illness or pressure or a visible increase in abdominal girth with symptoms at least 1 day per week and active for 3 months, with onset of 6 months and without a predominance of pain and alteration in bowel habits. Bloating too may occur as an isolated symptom, but may also be associated with irritable bowel syndrome (IBS), functional constipation/diarrhea/dyspepsia.

Abdominal bloating and distension has multiple pathophysiological basis of which gut microbiota, foods and visceral hypersensitivity are most important. Multiple disorders of gut-brain interaction are associated with bloating.

Belching may be supragastric or gastric in origin. The two conditions differ somewhat in pathophysiological basis and can be differentiated by impedance manometry. A comprehensive history and clinical observation may help to differentiate the two.

Supragastric belching is a voluntary behavior disorder (aerophagia), while gastric belching is an involuntary disorder (physiologic). Supragastric belch is characterized by too frequent belching (up to 20 per minute); it does not occur during sleep, talking and distraction and increases with stress. Patients with severe and frequent belching often describe that their belching initially started with bloating or a bothersome sensation in the stomach. It is mostly unrelated to meals. The associated comorbid conditions include anxiety and neurosis.

Gastric belch, on the other hand, is less frequent (few per hour) and occurs with greater force. It occurs after ingestion of meals and CO2 -containing beverages. GERD and functional dyspepsia are the usual comorbidities. The principles of treatment are to empty the colon, improve motility, restriction of foods that generate gas and manipulation of gut microbiota.

Pharmacological treatment includes baclofen (both in supra and gastric belching) and PPIs in GERD-associated belching.